Inspection on 25/10/06 for Woodlands Nursing Home

This inspection was carried out on 25th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Woodlands Nursing Home 01/08/07

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Woodlands Nursing Home Butterley Hill Ripley Derbyshire DE5 3LW Lead Inspector Steve Smith Key Unannounced Inspection 25th October 2006 09:40 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Woodlands Nursing Home DS0000066012.V313564.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Woodlands Nursing Home DS0000066012.V313564.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodlands Nursing Home Address Butterley Hill Ripley Derbyshire DE5 3LW Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01773 744919 Westwood Care Homes Limited Mollie Ann Hardy Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (36), Physical disability (4) of places Woodlands Nursing Home DS0000066012.V313564.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7 February 2006 Brief Description of the Service: The Woodlands Care Home has been purpose built and is registered for the care of 40 elderly Residents. The Home is registered to permit the admission of Residents with nursing and personal care needs. A condition of registration allows the Home to admit up to four younger adult Residents (50 - 65 years) with physical disability needs. The home is situated close to the town centre of Ripley. The Woodlands Care Home provides a pleasant environment for the Residents and accommodation is provided on two floors. There is a passenger lift and staircase access to the first floor facilities. There are two main lounge/dining areas and a mix of single and double bedrooms are provided. Five of the single bedrooms are provided with en-suite facilities. The home has adequate provision of assisted bath/shower facilities throughout. All bedrooms are fitted with TV points and the call/alert system operates in all areas of the home accessed by Residents. The attractive grounds of the home are accessible to the Residents. Support services are in place with a choice of General Practitioners, and chiropody, dental, optician and other services arranged as appropriate. The charges made for a room at The Woodlands range from £311.00 to £501.15 a week, dependent on the size of room, the facilities provided, whether the room is a double or single room, and whether residential or nursing care is required. These charges are for Residents who are over 65 year of age. For Residents who are aged between 50 and 65 year of age, and therefore judged to be younger adults with a physical disability, the charges range from £434.90 to £546.40 a week, again dependent on whether the room is a double or single room, and whether residential or nursing care is required. Woodlands Nursing Home DS0000066012.V313564.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in just over 5.5 hours. Discussion was held with two Residents, whose records were also ‘case tracked’, and the Deputy Manager of the Home. However, the Inspector did not speak to staff. A number of records were examined, and a number of the Residents bedrooms and all public areas of the Home were examined. This inspection was carried out with the assistance of the Deputy Manager. The Commission’s pre-inspection questionnaire had been returned by the Manage, but the Commission’s questionnaire sent out to a selection of Residents had not been returned by any Resident. What the service does well: What has improved since the last inspection? Woodlands Nursing Home DS0000066012.V313564.R01.S.doc Version 5.2 Page 6 Since the last inspection, that took place in February 2006, the Registered Provider had made the following improvements to the Home: The kitchen had been refurbished. Improvements had been made to the physical environment of the Home. An improved record of financial transactions, in Residents records, had been provided. The new Registered Provider had ensured that all policies and procedures had been brought up to date in the Home. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Woodlands Nursing Home DS0000066012.V313564.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Woodlands Nursing Home DS0000066012.V313564.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2 & 3. The quality in this outcome group was ‘Adequate’. This judgement was made using available evidence including a visit to the Home. The Registered Provider’s statement of purpose and Residents Guide required updating, to ensure that prospective residents would be adequately informed of the operation of the Home prior to deciding to move there. All new Residents moving to the Home were appropriately assessed prior to their admission, so that they were reassured that their needs would be met. EVIDENCE: The Registered Provider’s statement of purpose was examined and found to be appropriately completed, although the Registered Provider had not included the physical environment standards met by the Home. A summary of these standards was also missing from the Residents Guide. In September 2006, the details to be included within the Resident’s Guide where significantly updated by the government, but the Deputy Manager said that the Manager would Woodlands Nursing Home DS0000066012.V313564.R01.S.doc Version 5.2 Page 9 have been unaware of this change, and so the Guide was awaiting the necessary updates. All privately funded Residents had been provided with a copy of the Home’s contract when purchasing their care privately. However, the Deputy Manager said that those Residents supported by a Social Services Dept had not been provided with a statement of terms and conditions of residency. When new Residents were admitted to the Home, the Manager was provided with a summary of the needs of each person, completed by the Social Services Dept Care Manager supporting each Resident. If the Resident was self-funding from the outset, the Deputy Manager said that the Manager completed her own summary of needs, which were seen during the inspection. As a result of these two assessments, Residents’ needs would be appropriately met in the home. Standard 6 does not apply to this Home. Woodlands Nursing Home DS0000066012.V313564.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 & 11. The quality in this outcome group was ‘Adequate’. This judgement was made using available evidence including a visit to the Home. Residents’ health and personal care needs were being met, as demonstrated within care plans. However, safe medication procedures needed to be updated to ensure that Residents health care needs were always met. EVIDENCE: To help assess Standard 7, the Resident’s Plan of Care, the records of four Residents were examined, for the purpose of case tracking. All of the basic information, concerning each Resident, was found to be in the files examined. However, files did not contain a section recording each Resident’s choice of what furniture etc, was to be provided by the Registered Provider in their bedroom. Copies of the initial assessment completed by the Social Services Care Manager, where one was involved, were also not available in the files. However, the staff in the Home had completed their own initial assessment of needs for each of the four Woodlands Nursing Home DS0000066012.V313564.R01.S.doc Version 5.2 Page 11 Residents. There were also good quality care plans and risk assessments available in each record examined, providing staff with information to met Residents needs. However, the information tended to only relate to medical issues. The Manager had not ensured that Residents’ possible limitations of choice, freedom and decision-making abilities, if they were suffering from dementia, were formally recorded and reviewed at regular intervals. The files showed that records of events affecting each Resident were kept. However, only the briefest of records was kept of the formal reviews of care undertaken in the Home. The Commission recommends that these reviews should be carried out on at least a six monthly basis, and should be signed by each Resident, where they were able. However, where Residents were judged unable to sign their records, the Manager needed to decide with relatives which relative should act as the Resident’s ‘representative’ and to sign the record as such. Residents’ records were easy to read, with regular entries being made. The files were well organised, with different sections, and they were securely stored. However, none of the files contained a confidential section, in any of the four files examined. In two of files, the recording by one member of the nursing staff lacked a professional approach, and needed attention. Within the daily record of events in all of the files, a nurse was found to frequently ask other staff to monitor the condition of the Resident – ‘Please observe’. However, subsequent entries in the records did not refer to these requests, so it was not possible to see any outcome of the requests to ‘Please observe’. Staff of the Home were appropriately maintaining the records of Residents health needs, although a record of nutrition taken within the Home was not being maintained for each Resident. A Chiropodist was observed giving treatment to Residents in one of the lounges of the Home. Other Residents were watching treatment being provided. The appropriateness of this was discussed with the Deputy Manager and the Chiropodist, and the Chiropodist moved her care of Residents to the room provide for this treatment by the Manager. All medication and the method of distributing it to Residents were examined. A good system was found, although three issues needed attention: The Medication Administration Record (MAR) sheets did not all start on the same date, therefore signatures by staff distributing the medication, were required in different places on many of the MAR sheets. The MAR Woodlands Nursing Home DS0000066012.V313564.R01.S.doc Version 5.2 Page 12 sheets should all require signing in the same place. This helps to ensure that all medications are given out correctly, and enables the Manager to easily check that this had been done correctly. None of the MAR sheets had been completed by the pharmacy prior to supplying them to the Home. Senior nurses in the Home completed all details on the MAR sheet in pen. Medication was not supplied to the Home in Medidose or Nomad containers. As a result, there was no way the distribution of medication could be safely or easily checked throughout the month by the Manager. Two Residents were spoken to about life in the Home. They both said that staff were very good at listening to their views on how they liked to be cared for and staff would carry out their wishes. They said that their care needs were always met with dignity and respect. As a result, they felt very safe in the Home, and appeared to have a strong sense and appearance of well being – ‘Staff do it my way.’ ‘Yes, staff are pretty good at doing thing the way I want.’ Residents were also asked about their wishes following their death at the Home. They both said that no one from the Home had discussed this with them, but they had planned this with their family members. Woodlands Nursing Home DS0000066012.V313564.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15. The quality in this outcome group was ‘Good’. This judgement was made using available evidence including a visit to the Home. Residents preferred lifestyles were respected by the Home. They were able to receive visitors and to exercise choice and control over their lives. However, Residents were not always offered a choice at all meals provided by the Home. EVIDENCE: Two of the Residents were asked about the activities provided in the Home. One said that activities used to be arranged by an Activities Coordinator, but sadly she had left the Home very recently. As a result the Resident said that no activities were now organised. One of the Residents said that she needed staff assistance to get up and go to bed – ‘Staff are pretty good at doing this’, she said. The other Resident said that when offering assistance – ‘Staff always do it my way.’ Both said that staff were very good at listening to Residents views and requests and meeting their needs. Woodlands Nursing Home DS0000066012.V313564.R01.S.doc Version 5.2 Page 14 Both Residents said that they could go to bed and get up whenever they liked – ‘I get up at 8.00 in the morning and go to bed at about 10.00 or just after in the evening.’ ‘I always decide (what time I get up and go to bed each day).’ Both Residents also said that they had one bath a week, and that they had never asked nor been offered more baths per week. Both Residents said that both male and female staff work at the home. One Resident said that she always requested a female member of staff to assist her with bathing, which was always arranged by the Manager. Neither Resident was able to name their keyworker from the staff group. Neither Resident had been out to the shops with staff, as this was not offered by the Manager. One Resident said that her relatives regularly took her out, and that she greatly enjoyed these events. The other Resident said that she spent time in the garden of the Home when the weather allowed. Relatives and friends of Residents were able to visit at any time, and could always be seen in private - ‘I can always see (my relatives) in private ,in my bedroom, if I wish.’ Both Residents said that staff ‘… knock and open the door (to my room), I am not expected to say ‘come in’.’ Residents said that their mail was always delivered unopened, and that the Home was a ‘non-smoking’ home. The Residents said that meals were always good - ‘A good choice is offered at breakfast’. However – ‘No choice is offered at lunch time or teatime. At teatime it is always sandwiches and a sweet.’ ‘If I don’t like it (at dinner time), I leave it. No one has ever offered a different meal to me.’ Woodlands Nursing Home DS0000066012.V313564.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18. The quality in this outcome group was ‘Good’. This judgement was made using available evidence including a visit to the Home. Complaints and concerns made to the Registered Provider or Manager were addressed to meet Residents needs. The protection policies and procedures provided meant that Residents were well protected. EVIDENCE: Both Residents said that if they had a complaint to make they ‘would tell the Matron or one of the senior nurses’, and it would be investigated. One said that she had never had to do this, but the second said that she had done this on one occasion. The Resident said that she was very pleased with the action taken by the Manager. This demonstrated the responsiveness of the Registered Provider and Manager to the comments made by Residents. The Commission had not received any notice of complaint since the last inspection of the Home in February 2006. Good procedures and records were maintained of written and verbal complaints. Since the last inspection one verbal complaint had been made, which was satisfactorily resolved. The Registered Provider’s complaints procedure also detailed that all complaints would be responded to by a Registered Provider or Manager within at least 28 days. Woodlands Nursing Home DS0000066012.V313564.R01.S.doc Version 5.2 Page 16 The Registered Provider had a Safeguarding Adults procedure that included a ‘Whistle Blowing’ policy. There were also copies of the Public Interest Disclosure Act of 1998 and the Dept of Health’s policy called ‘No Secrets’ available in the Home. It was confirmed that all allegations and incidents of abuse would be promptly followed up and that all actions taken would be recorded. The policies and practices laid down by the Registered Provider ensured that all staff understood physical and verbal aggression by Residents. The Deputy Manager also said that a policy was available to staff stating that they could not benefit from Residents wills. Woodlands Nursing Home DS0000066012.V313564.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 21, 22, 24 & 26. The quality in this outcome group was ‘Adequate’. This judgement was made using available evidence including a visit to the Home. The Home was well maintained throughout, providing all Residents with a safe, comfortable environment in which to live. EVIDENCE: A tour was made of the Home, which included a sample of the bedrooms of the Residents. The Home was appropriately decorated throughout, and the lounges and dining rooms were attractive, pleasant to sit in, and were provided with the appropriate items for the Residents. The bedrooms seen provided satisfactory space for each Resident. However, a number of items needed to be addressed within the Home: Woodlands Nursing Home DS0000066012.V313564.R01.S.doc Version 5.2 Page 18 1. In the corridor by bedrooms 1-5, a strong smell of urine was apparent that needed to be addressed. This might well include replacing the carpeting along that corridor, and possibly in some bedrooms. 2. The bathrooms in Blue Wing and Peach Wing had an amount of furniture/wheelchairs stored within them, making them unusable. The items needed to be removed and the bathrooms brought back into use. 3. A large number of staff call lines were not coloured red and were the colour of the light pull lines. These needed to be changed to red lines. 4. In double bedrooms Residents were not always provided with their own wardrobe and drawer space. Residents using these bedrooms needed to be provided with their own wardrobe and drawer space. 5. Residents bedrooms were not always provided with two comfortable chairs. Woodlands Nursing Home DS0000066012.V313564.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28 & 29. The quality in this outcome group was ‘Adequate’. This judgement was made using available evidence including a visit to the Home. Nursing and care staffing was provided to meet the needs of Residents. However, the Manager needed to ensure that appropriate recruitment practices were always followed when employing new members of staff to safeguard Residents welfare. EVIDENCE: Staffing provided in the Home was compared with the details provided by the Residential Forum. This showed that during the four weeks beginning 21 August 2006, the Home was providing sufficient care hours to meet the needs of Residents. These figures were calculated without the Manager’s working time included, as recommended by the Residential Forum. Across the four weeks reviewed, 16 separate staff were found to have worked at least one double shift, and usually much more often, amounting to 12 hours in one day. One member of staff was found to have worked as much a 59.5 hours in one week, followed by two weeks of 52.5 hours each week. None of this encourages staff to meet the needs of Residents in a kindly, understanding and patient manner, and is to be strongly discouraged. Woodlands Nursing Home DS0000066012.V313564.R01.S.doc Version 5.2 Page 20 At the time of this inspection it was found that well under 50 of care staff had a qualification of at least NVQ level 2 in Care; 5 out of a total of 21 care staff. However, a further 6 care staff without the qualification were undergoing training. The records of two new staff employed during the past 12 months were examined to see whether the Manager had obtained all relevant information about them. The records showed that incomplete information was obtained. Both members of staff had provided a photograph and Criminal Record Bureau (CRB) information was available. One of the staff files contained only one reference. One of the members of staff had apparently provided a full history of previous employment, but without providing the dates of each job and the dates of any employment breaks. The other member of staff had provided none. Therefore, significant improvements were needed in this area, as the recruitment procedures did not fully protect Residents from possible harm. Woodlands Nursing Home DS0000066012.V313564.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 & 38 The quality in this outcome group was ‘Adequate’. This judgement was made using available evidence including a visit to the Home. The Registered Provider needed to complete a record of a monthly ‘inspection’ of the Home to ensure that Residents needs were being continually met. The Registered Provider and Manager needed to address all of the Quality Assurance issues to ensure Residents care was maintained at a positive standard. EVIDENCE: The Deputy Manager said that the Manager had obtained her qualification at NVQ level 4 in Management. The new Registered Provider had begun to ‘inspect’ the home, and to complete a report on that ‘inspection’ for the Manager, on a monthly basis, as required by Regulation 26. Woodlands Nursing Home DS0000066012.V313564.R01.S.doc Version 5.2 Page 22 The new Registered Provider had also begun to review the operation of the Home to ensure that Quality Assurance measures were in place. However, a report had not been produced at the time of this inspection. The Deputy Manager was able to show that the personal money of Residents was maintained satisfactorily. The training required by the Regulations was examined. This showed that Moving and Handling training and Fire Safety training had been provided for all necessary staff. However, First Aid training was required by two staff and two staff were also in need of Food Hygiene training. In addition, Infection Control training was required by five staff. In addition to the above required training, the Deputy Manager said that training was also provided on Dementia, Dying and Bereavement, Incontinence and Abuse Training. All Residents had been risk assessed to determine their vulnerability and measures had been put in place to provide protection where necessary. The Registered Provider had complied with all necessary legislation, such as the Health and Safety at Work Act 1974, and the Manual Handling legislation of 1992. The Deputy Manager was able to show that the Manager had provided risk assessments on the working conditions of staff; that is for care staff, catering staff and domestic staff, and had provided a written statement of the policy, organisation and arrangements for maintaining those safe working practices in the Home. The Deputy Manager was also able to show that all accidents, injuries and incidents of illness or communicable disease were recorded and reported to the relevant government bodies. She also said that, with the assistance of the Fire Service, fire safety notices were posted in relevant places around the Home, which were observed during the inspection. Woodlands Nursing Home DS0000066012.V313564.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Woodlands Nursing Home DS0000066012.V313564.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 5 Requirement The Registered Providers and Manager need to review the Residents Guide and update it in line with the legal changes that came into force in September 2006. Timescale for action 20/12/06 2. OP1 5 3. OP19 23 A copy of the Home’s terms and conditions of residency must be supplied to all Residents supported by Social Services Depts. The bathrooms in Blue Wing and Peach Wing must have the furniture/wheelchairs removed, due to fire safety, and the bathrooms brought back into use. The Registered Provider and Manager must check, and hold documentary evidence, that all new staff employed have satisfied the requirements listed in Regulation 19 and Schedule 2 of the Care Homes Regulations 2001, amended in 2004. DS0000066012.V313564.R01.S.doc 30/01/07 20/12/06 4. OP29 19 20/12/06 Woodlands Nursing Home Version 5.2 Page 25 5. OP33 24 The Registered Provider must address the Quality Assurance issues listed within Standard 33.1 to 33.7. The Registered Providers and Manager must ensure that all appropriate staffing receive training in First Aid, Food Hygiene and Infection Control. 28/02/07 6. OP38 13 & 18 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Refer to Standard OP1 No. 1. Good Practice Recommendations The Registered Provider should ensure that the statement of purpose contains all of physical environment standards listed in Standard 1.1, and that these are summarise in the Residents Guide to the Home. A record should be maintained, in each Resident’s file, of what furniture a Resident required within their bedroom, in line with Standard 24.2. The initial assessment, completed by the Social Services Dept Care Manager, should be available within in each Resident’s file. Residents plans of care should include all aspects of a Residents life and not simply deal with medical issues. The Registered Provider needed to ensure that each Resident suffering with dementia, or their representative, has had the opportunity to discuss their rights to choice, freedom and decision-making while staying in the Home. The outcome needs to be recorded in each Resident’s records, at least on a 6 monthly basis. The Manager needs to complete formal 6 monthly reviews of care with Residents. Those attending the review should 2. OP7 Woodlands Nursing Home DS0000066012.V313564.R01.S.doc Version 5.2 Page 26 include the Resident, their relatives and representative, and staff from the home. Where Social Services Depts carry out annual reviews of care this could be one of the 6 monthly reviews. The Registered Provider and Manager should review the recording made by staff and ensure it is always completed in a professional manner. When nursing staff use the Resident’s record of events to ask other staff to carry out tasks, such as ‘Please observe’, the task should be addressed on each entry following until the staff member requesting the task signs it off as no longer needed. 3. OP8 A record should be maintained of all meals taken by each Resident staying in the Home. The Chiropodist should only provide chiropody treatment to Residents in the room provided by the Manager. 4. OP9 The Medication Administration Record (MAR) sheets should all start and finish on the same date. All MAR sheets should be completed by the pharmacy in typed script to ensure accuracy and legibility. The Registered Provider and Manager are encouraged to introduce the Medidose or Nomad system of supplying and distributing medication to Residents, as this would allow easy accounting of the medication by the Manager and the Commission. 5. OP11 All Residents should be provided with an opportunity to plan their funeral arrangements shortly after moving to the Home. The Activities Coordinator should be replaced as soon as possible. In the mean time the Registered Provider and Manager should ensure that a member of staff has the time to arrange activities to entertain Residents on a daily basis. Residents should have the opportunity to have more than one bath each week. Keyworkers for each Resident should make themselves know to the Resident and ensure that they carry out all Woodlands Nursing Home DS0000066012.V313564.R01.S.doc Version 5.2 Page 27 6. OP12 necessary tasks for the Resident. Staff should be made aware of those Residents who should be encouraged, following staff knocking on their bedroom door, to invite staff into their bedrooms and those Residents who can no longer do this. 7. OP15 At least two choices should be offered at the lunchtime and teatime meal each day, with fixed alternatives available should they be needed e.g. soup, fish, pie etc. The strong smell of urine along the corridor by bedrooms 1-5 should be addressed. This might include replacing the carpeting. All staff call lines, throughout the Home, need to be coloured red, to distinguish them from light pull lines 9. OP24 In double bedrooms Residents need to be provided with their own wardrobe and drawer space. All bedrooms should be provided with comfortable seating for two people or four people in double bedrooms. However, this could be discussed with each Resident, or their Representative, and comfortable seating for one person could be provided if they agreed, and if this was recorded within each Resident’s Care Plan. 10. OP27 The Registered Provider and Manager should review the length of time nursing and care staff are allowed to work in the Home, and where possible limit this to no more than one shift per day, of approximately 8 hours, and 40 hours each week. The Registered Provider should ensure that at least 50 of care staff are trained to at least NVQ level 2 in Care as soon as possible. 8. OP19 11 OP28 Woodlands Nursing Home DS0000066012.V313564.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Woodlands Nursing Home DS0000066012.V313564.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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